A 78-year-old man who broke his hip at home had to wait for four days for an operation at Waikato Hospital in 2013.
That is more than double the optimal time for acute surgery, the Health and Disability Commissioner, Anthony Hill, said in a report today.
The man, Mr A, died in July 2013, just nine days after being admitted to hospital.
Mr Hill said the man, who had emphysema and a genetic disorder, went to the hospital emergency department mid-morning on a Friday and was diagnosed with a displaced left neck of femur fracture.
He was admitted to the orthopaedic service that afternoon where a consultant orthopaedic surgeon, Dr J, opted for a total hip replacement procedure the next morning. However, at 8am that day, a consultant orthopaedic surgeon, Dr C, decided that because of the seriousness of other patients awaiting surgery, Mr A would have to wait.
He was still waiting on Monday and had the surgery on Tuesday evening.
"This was over double the optimal time frame (up to 48 hours) for such acute surgery," Mr Hill said.
Next morning, Mr A showed signs of deterioration. He didn't respond to fluid resuscitation and deteriorated further. Mr Hill said the Waikato District Health Board used an Adult Deterioration Detection System (ADDS) observation tool, under which a score of 6 to 7 indicated that escalation should occur and a registrar be contacted.
However, Mr Hill said that on day seven - two days after the operation - his ADDS score had risen to 11, "owing to increasing shortness of breath, ongoing hypotension, and poor urinary output".
He was "escalated" to intensive care staff and then to the hospital's High Dependency Unit on Day 13. When his condition continued to deteriorate, he was placed on a palliative care pathway the following day, but died later that day.
The DHB told Mr Hill that: "It was not the delay that caused Mr A's unexpected death, but a post-operative acute medical event".
Nevertheless, Mr Hill said the standard of care breached patient rights. In particular, there was a delay in undergoing total hip replacement surgery of over double the optimal time for such acute surgery. And there was inadequate post-operative care, particularly a failure to call on a senior doctor when Mr A deteriorated on days six and seven.
Mr Hill was also critical that Dr C did not document his rationale for the delay in surgery. He added that "Waikato DHB has acknowledged that elective surgery could have been cancelled to create theatre capacity for Mr A." But, it represented "a service-level failure that could and should have been avoided."
Mr Hill's recommendations to the DHB included that it apologise to the family and conduct a scheduled audit of the standard of care provided to acute patients who have presented with a hip fracture.
The DHB told RNZ it accepted the findings. Its executive director of Waikato Hospital Services, Brett Paradine, said it had apologised unreservedly to the family since the death and made significant changes.
These included increasing the number of dedicated orthopaedic operating theatres from three to four for use daily for elective and acute surgery. That occurred in September 2013.
Since October last year the DHB had also increased orthopaedic acute all-day sessions from seven-and-a-half to 10 a week. It also had a dedicated theatre for orthopaedic surgery on weekday evenings and had recently "ring-fenced" two theatres for acute orthopaedic surgery on weekends.
Mr Paradine said the DHB had also recruited an extra three orthopaedic senior doctors and planned to appoint two more. A new database recorded all acute patients awaiting surgery and the time they'd been waiting if it was over 18 hours.
He added the DHB carried out about 24,000 surgical procedures a year and the numbers of acute orthopaedic procedures had increased significantly over the past four years.